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Full text of "United States Navy Medical News Letter Vol. 44 No. 10, 27 November 1964"



N0V2 3i io4 




Vol. 44 



Friday, 27 November 1964 



No. 10 




CONTENTS 



MEDICAL ABSTRACTS 



The U.S. Naval Aural Rehabilitation Center 1 

Peritoneal Dialysis 5 

FROM THE NOTE BOOK 

Naval Medical Research Reports 8 

Filmstrip Series Available for Education of Diabetic 

Patients from PHS, DHEW 9 

Dr. Raskind Wins All-Navy Tennis Crown in Three 

Sets 9 

DENTAL SECTION 

Specialization in Dentistry 10 

Brief History of the Rubber Dam 11 

A Study of the Use of Home Reliners in Dentures _ 12 

Oropharyngeal Cancer in Bhopal 12 

Dietary Selections of Persons with Natural and Arti- 
ficial Teeth 12 



DENTAL SECTION (Cont'd) 

Personnel and Professional Notes 13 

OCCUPATIONAL MEDICINE 

Heat Illness and Some Related Problems 14 

RESERVE SECTION 

New Individual Drill-Pay Scales 19 

Naval Reserve Selection Board Dates Are Set 20 

New-Type MOB Orders On Way to Reservists 20 

MISCELLANY 

Report on New BUMED Film 20 

Advice on Contact Lenses 21 

Dr. Imus Honored by APA 21 

Egyptian MD at NavScolAvn Med ,-----_ 21 



- 



United States Navy 
MEDICAL NEWS LETTER 



Vol. 44 



Friday, 27 November 1964 



No. 10 



Rear Admiral Edward C. Kenney MC USN 
Surgeon General 

Rear Admiral R. B. Brown MC USN 
Deputy Surgeon General 



Captain M. W. Arnold MC USN (Ret), Editor 
William A. Kline, Managing Editor 



Contributing Editors 

Aviation Medicine Captain C. E. Wilbur MC USN 

Dental Section Captain C. A. Ostrom DC USN 

Occupational Medicine CDR N. E. Rosenwinkel MC USN 

Preventive Medicine Captain J. W. Millar MC USN 

Radiation Medicine CDR J. H. Schulte MC USN 

Reserve Section Captain C. Cummings MC USNR 

Submarine Medicine CDR J. H. Schulte MC USN 



Policy 

The U.S. Navy Medical News Letter is basically an 
official Medical Department publication inviting the 
attention of officers of the Medical Department of the 
Regular Navy and Naval Reserve to timely up-to-date 
items of official and professional interest relative to 
medicine, dentistry, and allied sciences. The amount 
of information used is only that necessary to inform 
adequately officers of the Medical Department of the 
existence and source of such information. The items 
used are neither intended to be, nor are they, sus- 



ceptible to use by any officer as a substitute for any 
item or article in its original form. All readers of the 
News Letter are urged to obtain the original of those 
items of particular interest to the individual. 

Change of Address 

Please forward changes of address for the News Letter 
to: Commanding Officer, U.S. Naval Medical School, 
National Naval Medical Center, Bethesda, Maryland 
20014, giving full name, rank, corps, and old and new 
addresses. 



FRONT COVER: The Center Patio of the U.S. Naval Hospital, San Diego, California. The hospital and grounds, 
covering an area of 92.2 acres, are located on a hilltop northeast of the downtown area of San Diego, in Balboa 
Park which overlooks the Pacific Ocean and San Diego Bay. The buildings are of modern construction, primarily 
of Spanish design, with the exception of the splendid new 1000 bed surgical wing, which is of modern concrete 
and glass. 

The operating bed capacity of the hospital is 1,891. The San Diego Naval Hospital, in addition to being a 
general hospital, operates special facilities for the diagnosis and treatment of Coccidioidosis, Tuberculosis, Neuro- 
surgery, Oncology, Plastic Surgery, Thoracic and Cardiovascular Surgery, Acrylic Ocular Prosthesis, and Clinical 
Radioisotopes. In a recent year there were 486,526 outpatient visits, 27,324 admissions to the hospital, 3,798 
deliveries, and 1,353 daily average occupied beds. — Editor 

The issuance of this publication approved by the Secretary of the Navy on 4 May 1964. 

U.S. NAVY MEDICAL NEWS LETTER 



N0V2 3J964 



The U.S. Navy Aural Rehabilitation Center 



CDR G. R. Hart MC USN — Director, Aural Rehabilitation Center, United States Naval 
Hospital, Philadelphia, Pennsylvania. 



The Aural Rehabilitation Center was established at 
the U.S. Naval Hospital, Philadelphia, Pa. on 15 July 
1944 by the Surgeon General of the Navy, VADM Ross 
T. Mclntire. This Center started operation on 7 August 
1944. Twenty years and 30,558 patients later it con- 
tinues today as the Aural Rehabilitation Center of the 
Navy. 

The criteria for the referral of active duty service 
patients to the Aural Rehabilitation Center are detailed 
in the Manual of the Medical Department, Article 12-3 
(1) CH 14, as follows: 

"Patients requiring aural rehabilitation shall not be 
transferred to a special treatment facility unless the 
true loss of hearing in the better ear is more than 30 
decibels in the conversational range (256-2048 cycles) 
or unless the hearing of the whispered voice in the 
better ear is less than 3/15. Authority for transfer 
shall be requested as soon as it is determined that these 
conditions exist." 

Although the rehabilitation patient load has decreased 
since the war years, the hearing problems and demands 
for hearing testing and evaluation have increased. The 
added awareness of noise-induced hearing loss and in- 
creased interest in preventive measures, as evidenced in 
BuMed Instructions 6260.6 of 1955 and 6260.6A of 
1959, have contributed to an increased demand for 
hearing tests and evaluation of noise-induced hearing 
loss, as well as the requirements for audiometric testing 
at the time of all examinations for enlistment, re-enlist- 
ment, discharge, and the annual physical examination 
of officers. 

Aural rehabilitation implies a thorough evaluation 
of the nature and cause of hearing loss and the applica- 
tion of all procedures directed toward the maximum 
utilization of residual hearing. The rehabilitation pro- 
cedure may involve one or more methods such as 
treatment of the ear and related regional disease, the 
use of a prosthetic device (hearing aid), the retraining 
and readjustment of the individual in the use of his 
residual hearing ability, instruction in the conservation 
of hearing, and final disposition of the patient, either 

U.S. NAVY MEDICAL NEWS LETTER 



by return to his regular or modified duties or separation 
from the service. 

In all probability, aural rehabilitation, in the minds 
of most people, is directed toward the retraining and 
readjustment of the hard-of-hearing individual who 
must turn to the use of a hearing aid in order to regain 
sufficient communicative abilities to earn a living and 
enjoy adequate social status. Aural rehabilitation in 
this sense consists of a four week course of auditory 
retraining, of speech (lip) reading and the fitting of 
and familiarization with an individual hearing aid. 

Generally speaking, this program operates to develop 
the patient's ability to recognize and use all related 
sensory stimuli which are of importance in every day 
communication, both of an auditory and a visual nature. 
For this reason speech (lip) reading is included in this 
program, not as an alternative to hearing, but as a 
related visual aid in the recognition and interpretation 
of auditory clues. In many instances, auditory clues 
come to a patient via his hearing aid. Many persons 
with a sensory-neural loss, however, discover that the 
amplification provided by means of a hearing aid is not 
a complete and satisfactory substitute for the hearing 
acuity that has been lost, particularly in the discrimina- 
tion of various sounds. These persons must learn that 
it is necessary to compensate for the auditory limitations 
inherent in a hearing aid by means of an increased 
awareness of the gestures, motions, expression, and 
mouth and facial movements that become an integral 
part of the process of communication. In this sense, 
the conditioning of the patient to amplified sound and 
the careful selection and issue of his individual hearing 
aid are the beginning of the training and daily class 
instruction extending over a period of four weeks. 

When an individual is admitted to the hospital for 
Aural Rehabilitation, he is assigned to one of the 
otologists of the ENT Service who assumes responsi- 
bility for securing clinical studies, complete clinical 
work-up, and final disposition of this patient. In con- 
sultation with the Chief of Service and the audioiogy 
branch of the ENT Service, the results of at least three 

: HOSF'^ 




View of Ear Mold Laboratory. In order to obtain the best possible functioning of hear- 
ing aids, individualized patient ear molds, are fabricated here ("tailor made") with preci- 
sion. However, special and constant care is also exercised in the accommodation of the 
ear to the mold. (Official U.S. Navy Photograph, Photographic Laboratory, USNH, 
Philadelphia, Penna.) 



consistent series of tests are evaluated and determination 
of the need for Aurai Rehabilitation is made. 

The final selection and issue of a hearing aid as a 
part of the Aural Rehabilitation program presupposes: 

1. Extensive series of hearing tests that must meet 
acceptable standards of consistency. Over sixty 
per cent of the patients tested are not given a 
hearing aid because of improved test results prior 
to admission to Aural Rehabilitation classes. 

2. Fabrication of individual ear mold with constant 
attention given to the accommodation of the ear 
to the mold. 

3. The selection of a hearing aid from a variety of 
aids available to each patient and suitable for his 
particular loss. Information is provided about 
each aid and final selection must meet certain 
criteria of acceptability including optimal per- 
formance as measured by actual test. 



4. Continued training in the use of the hearing aid. 
The patient is taught the care and use of the aid, 
the recognition of its limitations, and is helped in 
the preliminary adjustment period of hearing aid 
use. 

5. Continued emphasis on improved communication 
is maintained by the lecture and practice sessions 
in auditory training, speech reading and recogni- 
tion of typical audible and visual clues. 

Aural Rehabilitation has been adapted, also, to meet 
the needs of those individuals who suffer a slight loss 
of hearing or a loss which is limited to the higher 
frequencies with normal or near normal hearing in the 
mid- and lower frequencies. A hearing aid is of little 
or no value to this patient who, nevertheless, may miss 
many of the audible clues essential to good intelligibility 
and discrimination of sound. This patient must turn to 
speech reading as the only possible source of improve- 



U.S. NAVY MEDICAL NEWS LETTER 



merit in the understanding of the spoken word. Aural 
Rehabilitation for this patient consists of an under- 
standing of the physiology of hearing, the characteris- 
tics of his own hearing loss and of the problems typical 
of this hearing loss. It is safe to say that to an equal 
or greater degree than the hearing aid wearer this 
patient must learn to compensate for the loss of auditory 
clues by an increased awareness of audible and visual 
clues. 

More recently a new phase of this program has been 
introduced with the specific objective of instructing 
personnel with some slight impairment of hearing in 
the prevention of further damage by reason of exposure 
to noise. This phase includes the practical measure of 
fitting and issue of ear defenders (V-51R type ear plug) 
and instruction in their use by the ear mold technician. 

The term Aural Rehabilitation used in describing this 
program and the name of this clinic, and utilized as the 
basis of authority for transfer of patients to this Center, 
may overshadow or eliminate any consideration of 
other functions of this clinic in this hospital. If the 
transfer of an ENT patient to this facility is considered 
only in terms of requiring aural rehabilitation, a strong 
possibility exists that inadequate use may be made of 
a facility organized and equipped to receive and often 
solve other problems associated with hearing and speech 
disorders. Speech therapy, determination of need for 
a hearing aid, the value of an aid to a patient, the 
thorough evaluation and final diagnosis of hearing dis- 
orders, and degree of incapacity for duty are routine 
functions for which the clinic (by reason of physical 
equipment and personnel) is admirably suited. This 
could be readily overlooked if the transfer of patients 
is considered only because of expressed need or recom- 
mendation for Aural Rehabilitation. This is particularly 
true in those known instances where hearing aids are 
issued at some stations without thorough evaluation and 
adequate facilities for determination of the value of 
the hearing aid for the individual concerned. 

Constructed as hearing clinic, sound-treated through- 
out, the physical facilities are well suited to the evalua- 
tion of organic hearing loss. Equipped with double and 
single room testing areas, the clinic employs the latest 
and best equipment available. Standard pure tone and 
speech audiometers are complemented by GSR equip- 
ment, Bekesy Audiometry, SISI adaptors, delayed 
speech playback equipment, and the means of perform- 
ing an extensive variety of special tests. Personnel 
under the direction and leadership of the ENT De- 
partment are experienced in the administration of hear- 
ing tests and the evaluation of "problem" cases. The 
routine and the complicated hearing problems are well 
represented in the files of some thirty thousand hard- 
of-hearing "cases." This combination of physical facil- 
ity, equipment and personnel is responsible for the fact 
that many of the patients transferred for Aural Reha- 
bilitation because of the hearing loss measured in other 



medical facilities are returned to duty following a 
thorough evaluation which fails to verify the loss, and 
often directly contradicts it. Over sixty per cent of 
those sent for Aural Rehabilitation and hearing aids 
during the past few years have not required hearing 
aids. A few of these patients had been issued hearing 
aids prior to transfer. It might well be assumed that a 
large percentage of this group would have been issued 
hearing aids if transfer for rehabilitation purposes had 
not been accomplished. This is not necessarily a re- 
flection on the clinical judgment or audiometric evalua- 
tion of the referring hospital, but a tribute to the main- 
tenance of very accurate operating electronic equipment 
in the hands of experienced personnel. It provides suffi- 
cient testimony to confirm the wise decision of the 
Bureau of Medicine and Surgery requiring that all 
Naval and Marine Corps personnel suspected of suffi- 
cient hearing loss to require a hearing aid or separa- 
tion from active duty or duties should be transferred for 
full and final evaluation. By means of prolonged, repe- 
titive testing with insistence on accurate, consistent 
results, the individual is assured of proper evaluation of 
his disability, and the Navy is protected from unjust 
claims of disability. It is obvious that the Center is 
not being used by other medical facilities for full and 
final evaluation of all hearing losses prior to final dis- 
position, since many cases have been referred to this 
Center by the Navy Physical Review Council. Further 
evaluation has been requested in these instances in which 
separation from the service via other U. S. Naval hos- 
pitals and Physical Evaluation Boards has been ques- 
tioned as to the merits of the claimed disability. In 
some of these instances, personnel on temporary re- 
tirement with disability rating of 40% to 60% have 
been redefined as 10% disability or less following com- 
plete and extensive evaluation. One may well consider 
whether this type of complete hearing evaluation prior 
to final separation (despite the hardship of travel, etc.) 
might be a wise utilization of the Aural Rehabilitation 
Center which could result in economies of manpower 
and dollars for the U. S. Navy Medical Department. 
Perhaps additional emphasis should be given to the 
implications and procedures which are basic to the 
term 'Aural Rehabilitation." Statistics appear to indi- 
cate that some degree of rehabilitation is routinely ad- 
ministered by means of more intensive and extensive 
evaluation of hearing loss. Included in these statistics 
are those who were sent to duty because a hearing aid 
was not indicated. These figures could suggest that 
some "gave-up" and returned to the ways of the normal 
hearer during or following prolonged tests. They could 
point to others whose questionable hearing loss led to 
final psychiatric diagnoses. More recently, these statis- 
tics have highlighted those, who, upon revaluation of 
claimed disability following separation from service, ap- 
pear to have been in need of more extensive studies 
prior to separation. Not all "cases" of hearing prob- 



U.S. NAVY MEDICAL NEWS LETTER 



ADDENDUM I 



1963 (12 months) 

1964 (First 6 months) 



1963 (12 months) 

1964 (First 6 months) 



1963 (12 months) 

1964 (First 6 months) 





Total Services 

(Tests and Treatments) 

22,002 

10,096 




New Patients 
2084 
1230 








Military Personnel Visits 










n Patients Out-Patients 
Army Navy & MC 
1313 63 1321 
623 41 775 


A.F. 

159 
55 


Others 

372 

; ' 327 


O. P. 

Total 
1915 
1198 


TOTAL 

3228 
1821 




Dependents 












Visits 
1092 

824 




Services 
2368 

1877 







Others 
(VAB, FBI, Civil Service, Retired, etc.) 



1963 (12 months) 

1964 (First 6 months) 




Visits 

820 
629 


Services 
2823 
1649 






Aural Rehabilitation Patients 






1963 (12 months) 

1964 (First 6 months) 


Number Sent 
128 

49 


Number given 
Rehabilitation 

40 
21 

Speech Services 


Hours of 
Rehabilitation 

3001 
1038 


Hearing A ids 
24 

16 


1963 (12 months) 

1964 (First 6 months) 


Military 
371 

225 


Dependent 

410 
389 




Veterans 

Administration 

118 

147 



lems are resolved to the satisfaction of everyone con- 
cerned. Nevertheless, more (not less) testing and in- 
formation are necessary. 

This clinic's twenty years of exeperience in dealing 
with the hard-of-hearing service member on active duty 
makes possible one final observation. In the man whose 
auditory acuity has been '"improved" by a hearing aid, 
his hearing has been "aided", not restored. No flat 
answer can be given to the question of qualifications 
for continued duty on the basis of standard test results. 
Only when hearing loss is properly evaluated as to type 
and degree, only when the demands of rate and station 
have been weighed, and total performance of the indi- 
vidual has been contrasted, can a justified recommen- 
dation of separation from service or retention in service 
be made. 

A unique opportunity exists here for a thorough 
evaluation and determination of fitness for duty by the 
staff of the ENT Service. The days spent in complete 
evaluation of hearing loss and hearing problems, ob- 



servations of attitude*,motivation, and individual use of 
hearing aid, during the course of Aural Rehabilitation, 
provide the opportunity for an informed and considered 
judgement prior to a recommendation for continued 
duty, a waiver of physical standards, or separation from 
the Armed Services. 

If concentration on the theme of Aural Rehabilitation 
tends to overshadow other functions of the Hearing 
and Speech Clinic, specific mention should be made of 
the facilities that exist for the improvement of the other 
member of the team essential to auditory communica- 
tion, namely, intelligible speech. 

Speech therapy which may play a part in the Aural 
Rehabilitation process exists, nevertheless, as an inde- 
pendent discipline. Treatment of varied speech dis- 
orders is extensive and is limited only by the fact that 
speech instruction is usually individual instruction, and 
individual instruction is time consuming. Many children 
(dependents of Navy, Marine Corps, Army, Air Force 
and Coast Guard personnel) are sent for developmental 



U.S. NAVY MEDICAL NEWS LETTER 



disorders of speech. All are evaluated, and some are 
scheduled for therapy; others are directed to various 
schools and local agencies for treatment where it is 
available. Pre-school children who have hearing prob- 
lems and who have been fitted with a hearing aid at 
age of two or three years are included in this group. 
However, children are only a segment of the typical 
schedule of patients seeking help for stuttering, aphasia, 
local paralysis of phonation, dysphonias, and other 
possible disorders of speech. In a special category, the 
reeducation of the laryngectomized patient is under- 
taken through the teaching of esophageal or pharyngeal 
voice. 

The speech therapist, the audiologist, and th£ con- 



sultant service member of other departments work 
toward a total program of improvement for those who 
may suffer impairment of either the sending (speech) 
or the receiving (hearing) apparatus of communication. 
In this atmosphere, a class of EENT Technicians un- 
dergoes training in a facility providing excellent op- 
portunity to become acquainted with the gamut of 
special test equipment and hearing problems. 

It is doubtful that a classification of patients would 
be of particular interest, but for the statistically minded, 
Addendum I provides information on both the type and 
number of patients seen at the Aural Rehabilitation 
Center, Hearing and Speech Clinic, U. S. Naval Hos- 
pital, Philadelphia, Pa. in the past eighteen months. 



Peritoneal Dialysis 



LT D. L. Kettering MC USN. From the Proceedings of the Monthly Staff Conferences 
of the U.S. Naval Hospital, NNMC, Bethesda, Md., 1963-1964. 



The purpose of this paper is to present a simple, 
effective technique for the management of acute or 
exacerbations of chronic renal failure which is applic- 
able by any Naval Medical Officer in practically any 
locality with a minimum of laboratory and professional 
support. This technique is peritoneal dialysis which 
entails lavaging of the peritoneal cavity with a balanced 
electrolyte solution. 

The peritoneum is a serous membrane which lines 
the wall of the abdomen and its viscera and consists of 
two layers: a stroma of loosely arranged connective 
tissue bundles covered by flat polygonal mesothelial 
cells. The peritoneum is well supplied with capillary 
and lymphatic networks and acts as an inert semiper- 
meable membrane through which crystalloids and water 
move freely in both directions depending on the osmo- 
larity of the fluid compartments. 

Ganter, a German physician, is given credit for first 
treating patients by peritoneal dialysis in 1923.' Selig- 
man, Frank and Fine did much of the basic clinical 
work in this country in the 1940's. 2, :l 4 Grollman gave 
further impetus to this technique leading to the present 
widespread clinical use today/' " 

TECHNIQUE 

The two basic components for peritoneal dialysis are 



a lavage tube and sterile electrolyte solutions. 

There are plastic and nylon lavage catheters pro- 
duced commercially. We have found an 8-inch poly- 
vinyl (chloride) ridged tube with 60 hand-punched 
holes to be very effective. The ridging prevents kinking 
and blockage by omentum. The tube is placed in the 
posterior pelvis of the peritoneal cavity through a 
trochar in a small midline incision 1-2 inches below 
the umbilicus. The surrounding tissues are sutured 
snugly in layers about the catheter. This can be per- 
formed at the bedside under local anesthesia. Once 
in place, the tube can be used for several weeks, if 
necessary, without change. 

(A slide was projected showing the details of the 
catheter in the abdomen.) 

Two liters of commercially available balanced elec- 
trolyte solution are rapidly run into the peritoneal cavity 
in 5-10 minutes. After 1-2 hours for dialysis across the 
peritoneal membrane, the electrolyte bottles are 
lowered and the fluid drains by gravity within 10-15 
minutes. The process can be repeated continuously or 
intermittently, depending upon the clinical status of the 
patient. If necessary, more than two liters can be in- 
fused at one time to speed the rate of dialysis. Com- 
mercially available electrolyte solutions are listed. 
(Figure 1) 



U.S. NAVY MEDICAL NEWS LETTER 



Fig. 1— ELECTROLYTE SOLUTIONS 



Solution 



Inpersol 
(Abbott) 

Peridial 
(Cutter) 

Dianeal 
(Baxter) 



Na K Ca Mg CI HCO 

m Eq/L m Eqt L m Eq/L m Eq/L m Eq/L m Eq/L 



140.5 



140.0 



141.0 



3.5 



4.0 



3.5 



1.5 



1.5 



1.5 



101.0 



102.5 



101.0 



44.5 



43.0 



45.0 



Calculated 
Osmolarity 
(m O sm./L) 
1.5% 7.0% 

Glucose Glucose 



371.5 



371.0 



372.5 



677.4 



677.0 



678.4 



Because most uremic patients are hyperkalemia, there 
is no potassium in the solution. As dialysis proceeds, 
it may be necessary to add rm. eq. KCL/L of lavage 
fluid to prevent hypokalemia, especially if the patient 
is on digitalis. If the patient is overhydrated, higher 
concentrations of glucose, such as 7%, may be used 
for rapid removal of edema fluid due to increased 
osmolarity of the lavage fluid. The solutions should be 
warmed to body temperature in a water bath to prevent 
diarrhea and abdominal cramps from bowel irritation. 
Ten mg. of heparin and 25 mg. of tetracycline are 
added to one liter of each lavage cycle to prevent 
blockage of the dialysis tube with fibrinocellular clots 
and as prophylaxis against peritonitis. 

After the physician has inserted the tube, the process 
of dialysis can be performed by a nurse or corpsman. 
One daily set of blood chemistries is usually adequate 
to regulate the number of lavages from day to day. 
The ECG serves as a sensitive index of hyperkalemia 
which can be easily obtained in the evening. The coma- 
tose patient requires no intravenous fluids or tube feed- 
ings during periods of continuous dialysis as he meta- 
bolizes the glucose from the lavage fluid. One accurate 
daily weight is the best index of the state of hydration. 

Doolan has demonstrated 80% equilibration of 
plasma and dialysate urea in one hour and nearly full 
equilibration in two hours.' The two-hour dialysis is 
adequate in ordinary cases, but where advanced potas- 
sium intoxication, severe uremia with acidosis, drug 
intoxication or intractable pulmonary edema is present, 
the one-hour dialysis is used. 

Grollman * has further modified the dialyzing fluid 
by adding human serum albumin in order to remove 
bilirubin from the serum of a severely jaundiced patient 
with serum bilirubin levels of 85 mgs.%. He was able 
to remove 250-270 mg of bilirubin in a single dialysis. 
This modification would be of use in removing other 
protein-bound substances such as barbiturates and sali- 
cylates from the serum more rapidly. 

CLINICAL USES 

Review of the recent literature shows the conditions 



in which intermittent peritoneal dialysis has been used 
clinically (Figures 2, 3, 4.). 

Fig. 2— INDICATIONS FOR 

PERITONEAL DIALYSIS 

I. Primary Renal Disease 

(a) Acute Renal Failure 

( 1 ) Acute tubular necrosis ; 

(2) Nephrotoxic Poisoning 

(3) Acute glomerulonephritis" 

(b) Acute exacerbation of chronic renal failure 

( 1 ) Exacerbation of underlying disease 

(2) Intercurrent infection 

(3) Surgical procedure 

Fig. 3— INDICATIONS FOR 

PERITONEAL DIALYSIS 

II. Non-Nephrotoxic Intoxication 

(a) Bromides 

(b) Barbiturates " 

(c) Salicylates 1 " 

(d) Methyl alcohol 11 ' 

(e) Glutethimide (Doriden) 11 

(f) Salt " 

(g) Boric Acid " 

Fig. 4— INDICATIONS FOR 

PERITONEAL DIALYSIS 

III. Miscellaneous 

(a) Hepatic Coma tr ' 

(b) Intractable edema M 

(c) Preoperative preparation ,e 

(d) Brain injury " 



U.S. NAVY MEDICAL NEWS LETTER 



(e) Uric acid nephropathy "■ ™ 
(f ) Failure of hemodialysis due to shock or 
hemorrhage tendencies 

I would like to describe briefly a case we treated 
on Ward 3 A by peritoneal dialysis: 

R. L. was a 23 year-old Caucasian male transferred to 
NNMC for management of acute renal failure second- 
ary to fat emboli and shock following fractures of the 
left tibia and fibula. 

On admission, the patient was comatose and had a 
tracheostomy tube, left leg in a cast and a positive 
right Babinski sign. The remainder of the physical 
examination was unremarkable. 

His urine output was 145 cc the day prior to trans- 
fer. Laboratory studies on admission revealed: BUN 
300 mg.%.; Na 130 m. eq.; K 5. 3 m. eq.; CI. 110 m. 
eq.; and Ca 3.5 m. eq. He received 134 peritoneal lav- 
ages over the following 18 days with the lowering of 
the BUN to 59 mg%., urine output of over two liters 
per day and regaining of consciousness. His hospital 
course was complicated by a stress duodenal ulcer with 
hemorrhage, bronchopneumonia, gram-negative infec- 
tion shock and death from ventricular fibrillation 41 
days after admission. 

These events illustrated the effectiveness of peritoneal 
lavage in acute renal failure and that the major cause 
of death today following acute renal failure is infection 
and not metabolic imbalance or cardiac decompensa- 
tion. 

CONTRAINDICATIONS 

Recent abdominal surgery, peritonitis, multiple ab- 
dominal wounds, and marked abdominal distention are 
contraindications to peritoneal dialysis. Potential wound 
breakdown, infection and hemorrhage have been listed 
as reasons not to use peritoneal dialysis after recent 
abdominal surgery until the 5th to 8th postoperative 
day."" However, Burns, et. al. have reported using 
this technique 56 hours after repair of a perforated 
duodenal ulcer with chemical peritonitis in a patient 
with chronic glomerulonephritis without incident to the 
laparotomy incision or patient.'" Bowel sounds returned 
after the first postoperative dialysis. If peritonitis de- 
velops during dialysis, antibiotics are infused into the 
peritoneal cavity and dialysis stopped. However, pa- 
tients with peritonitis and abdominal wound infections 
have been dialyzed successfully and this is not an ab- 
solute contraindication. Miller described a case of B. 
welchii peritonitis with acute renal failure successfully 
treated with peritoneal dialysis."' Multiple abdominal 
wounds make dialysis ineffective due to leakage of 
fluid. Marked abdominal distention has the inherent 
risk of bowel perforation from insertion of the trochar. 

COMPLICATIONS 

The complications of peritoneal dialysis are as fol- 



lows (Figure 5). 

Fig. 5— COMPLICATIONS OF 

PERITONEAL DIALYSIS 



MAIOR 

1 . Peritonitis 

2. Overhydration 

3. Perforation of Abdomi- 
nal viscus with Trochar 



MINOR 



1 . Obstruction of Catheter 

2. Leakage around Cathe- 
ter 

3. Bleeding from Trochar 
Insertion 

4. Abdominal Discomfort 

5. Ileus 

6. Hypoproteinemia 
Edema 

It is the opinion of those using this technique in 
recent years that it is safe and effective. (Figure 6). 



Figure 6 





No. Of Pts. 




Series 


seen 


Death. 


Burns, et. al. (Brigham)'" 


136 





Maxwell, et. al. (U San Fran) : " 


76 





Miller (Bristol, Eng) al 


45 





Pateras, et. al. (GWU)" 


30 





Cohen (Hamilton, Ont) 2:l 


14 





Doolan, et. al. (Oak. NH) 1 


II 





Etteldorf, et. al. (U of Tenn)" 


5 


1 * 


TOTAL 


317 


1 



* Overhydration of 3 month-old infant due to no glu- 
cose in lavage fluid. 



SUMMARY 

A relatively simple, safe, and effective means of 
treating renal failure has been presented. It has the 
practical military advantage of being applicable in small 
dispensaries or hospitals with a minimum of profes- 
sional and laboratory support, especially during times 
of national crises when transfer to large renal centers 
is not possible. 



BIBLIOGRAPHY 



Ganter, G.; Dialysis of Blood in Living Subjects. Muncken. med. 
Wchnschr. 70: 1478, 1923. 

Seligman, A. M., Prank, H. A., and Fine, J.: Treatment of ex- 
perimental uremia by means of peritoneal irrigation. J Clin Invest 
25: 211, 1946. 

Fine, J., Frank, H. A., and Seligman, A. M.: The treatment of 
acute renal failure by peritoneal irrigation. Ann Surg 124: 857, 
1946. 
4. Frank, H. A., Seligman, A. M., and Fine, J.: Further experiences 
with peritoneal irrigation for acute renal failure. Ann Surg 128: 
561, 1948. 



3. 



U.S. NAVY MEDICAL NEWS LETTER 



5. Grollman, A., Turner, L. B,, and McLean, J. A.: Intermittent 
peritoneal lavage in nephrectomized dogs and its application to 
the human being. Arch Int Med 87: 379, 1951. 

6. Grollman, A.: Acute Renal Failure. Springfield, 111., 1954. 
Charles C. Thomas. 

7. Doolan, P. D., Murphy, W. P. Jr., Wiggins, R. A., Carter, N. W., 
Cooper, W. C, Watten, R, H,, and Alpen, E, L. : An evaluation 
of intermittent peritonea] lavage. Am J Med 26: 831, 1959. 

K. Grollman, A. P., and Odell, G. B.: Removal of Bilirubin by 
Albumin binding during intermittent peritoneal dialysis. NESM 
267: 279, 1962. 

9. Etteldorf, J. N., Dobbins, W. T., Sweeney, M. J., Smith, J. D., 
Whittington, G. L„ Sheffield, J. A., and Meadows, R. W,: Inter- 
mittent peritoneal dialysis in the management of acute renal 
failure in children. J of Ped 60: 327, 1962. 

10. Hearn, R, E,, and Berry, W. G,: Peritoneal lavage, Hawaii M J 
17: 40, 1957. 

11. Schreiner, G. E.: AMA Arch Intern Med 102: 896, 1958. 

[2. Steinebaugh, B, J.: The use of peritoneal dialysis in acute methyl 
alcohol poisoning. AMA Arch Intern Med 105: 613, 1960. 

13. Miller, N. L. and Finberg, L.: Peritoneal dialysis for salt poison- 
ing. NEJM 263: 1347, 1960. 



14. Segar, W. E. : Peritoneal dialysis in the treatment of boric acid 
poisoning. NEJM 262: 798, 1960. 

15. Palmer, A. D. : The dying cirrhotic. G.P. 27: 82, 1963. 

16. Burns, R. O., Henderson, L. W., Hager, E. B., Merrill, J, P.: 
Peritoneal dialysis. Clinical experience. New Eng J Med 267: 
1060, 1962. 

17. Fisher, R. G. and Finigan, M,: Peritonea] dialysis: Its use in 
the correction of altered chemistry in a brain-injured patient. 
J Neurosurg 18: 535, 1961. 

18. Duke, M. : Peritoneal dialysis in leukemia and uric acid 
nephropathy. Am J Med Sci 245: 426-431, 1963. 

19. Barry, K. G., Hunter, R. H., Davis, T. E., Crosby, W. H.: Acute 
uric acid nephropathy. Mannitol diuresis and peritoneal dialysis. 
Arch Intern Med (Chicago) HI: 452, 1963. 

20. Maxwell, M. H„ et. al. JAMA 170: 917, 1959: Peritoneal dialysis. 

21. Miller, A.: Peritoneal dialysis. Brit J Urol 34: 465, 1962. 

22. Pateras, V. R., Watt, M. F., Kramer, N. C, Jacobson, M. H., 
and Parrish, A. E. : Peritoneal dialysis in the treatment of 
uremia. Med Ann of D.C. 31; 510, 1962. 

23. Cohen, H.: A clinical evaluation of peritoneal dialysis. Canad 
Med Assoc J 88: 932, 1963. 



FROM THE NOTE BOOK 



NAVAL MEDICAL RESEARCH REPORTS 

U, S. Naval Medical Research Institute, National Naval 
Medical Center, Bethesda, Md. 

1. Structural Transitions of Lysozyme: MR 005.06- 
0001.01 Report No. 23, May 1963. 

2. A Molecular Structural Basis for the Excitation 
Properties of Axons: MR 005.09-0020.02 Report 
No. 4, May 1963. 

3. The Maximum Sarcomere Length for Contraction 
of Isolated Myofibrils: MR 005.08-0020.01 Re- 
port No. 8, June 1963. 

4. Cytoecology of Temperature: MR 005.02-0001.07 
Report No. 1 1, September 1963. 

5. The Effects of Certain Cations and Antibiotics on 
Blood Digestion in Two Species of Mosquitoes: 
MR 005.09-1401.01 Report No. 8, December 1963. 

6. Human Reliability Implications of the U. S. Navy's 
Experience in Screening and Selection Procedures: 
MR 005.12-2003.01 Report No. 3, December 1963. 

7. Alterations in Flycolysis by Cell-free Rat Brain 
Homogenate Under High Oxygen Pressure: MR 
005.14-3001.02 Report No. 3, December 1963. 

8. Engineering in Biomedical Research, Lecture and 
Review Series No. 64-1, January 1964. 

9. Practical Solutions to Problems of Thirst in Closed 
or Open Spaces: MR 005.02-0011.01 Report No. 
3, January 1964. 

10. Digenetic Trematodes of Fishes from Palawan 
Island, Philippines. Part II. Five Opecoelidae, 
Including Three New Species: MR 005.09-1601.1 
.5, January 1964. 



1 1 . Digenetic Trematodes of Fishes from Palawan 
Island, Philippines. Part III. Families Hemiuridae 
and Lepocreadiidae: MR 005.09-1606.01 Report 
No. 10, January 1964. 

12. Unfinished Business. Lecture and Review Series: 
No. 64-2, March 1964. 

13. Effective Temperature Scale and Its Modiffications; 
MR 005.01-0001.01 Report No. 6, March 1964. 

14. Heat Stress During Training Operations: MR 
005.01-0001.01 Report No. 8, March 1964. 

15. A Cursory Survey of the Intestinal Parasites in 
Indigenous People of Nan-Kan Island, Matsu 
Archipelago: MR 005.09-1606.01 Report No. 11, 
March 1964. 

16. Soluble Proteins of Fresh Human Bone and Dentin: 
MR 005.12-5000.12 Report No. 8, March 1964. 

17. Studies on the Cell Envelope of Wolbachia Persica: 
MR 005.09-1200.02 Report No. 16, April 1964. 

18. Indirect Hemagglutination with the Trachoma 
Agent and Related Microorganisms: MR 005.09- 
1200.03 Report No. 6, May 1964. 

19. Studies on a Common Bedsonia-Group Antigen 
(CBA) Found in the Yolk of Hen's Eggs: MR 
005.09-1200.05 Report No. 3, May 1964. 

U. S. Naval Medical Research Unit No. 3, Cairo, Egypt 

I . Haemaphy salis cornigera shimoga subsp. n. from 
Southern India (Ixodoidea, Ixodidae) : MR 005.09- 
1402.3, April 1964. 



U.S. NAVY MEDICAL NEWS LETTER 



2. A Haemaphysalis kyasanurensis sp. n., a Member 
of the formosenis Group in Southern India and 
Ceylon (Ixodoidea, Ixodidae): MR.005.09-1402.3, 
April 1964. 

U. S. Naval Medical Field Research Laboratory, Camp 
Lejeune, N. C. 

1. The Reliability of Automobile Accident Experi- 
ence in a Military Sample: MR 005.12-2504-1.1, 
July 1964. 

2. Service Test of Foot-Powered Hypodermic Jet In- 
jection Apparatus: MR 005.12-6001.6, July 1964. 

3. Possible Role of T-Strain Mycoplasma in Nongon- 
ococcal Urethritis: MR 005.09-1501.1.5, August 
1964. 

U.S. Naval Air Development Center, Aviation Medical 
Acceleration Laboratory, Johnsville, Penna. 

1. Plotting and Analyzing Cumulative Response 
Curves in Operant Conditioning Studies: MR 005. 
13-0002.16 Report No. 12, June 1964. 

2. A Discussion of Medical Monitoring in Relation to 
Safety in Centrifuge Operations: MR 550.13- 
1004.11 Report No. 10, June 1964. 

3. Displacement and Durational Characteristics of 
Lever Pressing in Fixed Ratio and in Extinction: 
MR 005.13-0002.16 Report No. 13, July 1964. 



FILMSTRIP SERIES AVAILABLE FROM 

PHS, DHEW, FOR EDUCATION OF 

DIABETIC PATIENTS 

"Just One in a Crowd," a completely new filmstrip 
series for diabetes patient education, has just been 
released by the Public Health Service, U.S. Department 
of Health, Education, and Welfare. 

It is designed to help educate the 2,000,000 known 
diabetics and the 200,000 new diabetics that are being 
diagnosed every year. Each of these persons must be 
taught, under the direction of his physician, how to 
manage his disease. Each must be taught the rudiments 
of dietary control, physical health, insulin administra- 
tion, and several testing procedures — all at once. 

Prepared by the Diabetes and Arthritis Program, 
Division of Chronic Diseases, this six-part series pre- 
sents basic information on diabetes in a colorful and 
easily understood fashion. It contains an introductory 
lesson on diabetes, itself, two lessons on diet, lessons 



on physical health and medication, and a concluding 
lesson that reviews the entire course. Each fifteen- 
minute session is complete and can be used separately, 
followed by a question and answer period. 

The series comes in a set, with an instructor's 
manual, in slide or filmstrip format with the audio 
portion available on both tape and record. It is filmed 
in color on 35 mm frames and can be used in standard 
slide projectors. 

The filmstrip may be borrowed, free of charge, from 
the Public Health Service Audiovisual Facility, Atlanta, 
Georgia. 

DR. RASKIND WINS ALL-NAVY TENNIS 
CROWN IN THREE SETS 

For his second year in a row Lieutenant Richard H. 
Raskind MC USN, successfully captured the "All Navy" 
Tennis Championship. The defending champ won the 
honor at the All Navy Matches, played at Newport, 
R. I. 

A southpaw in the tennis field and a native New 
Yorker he was crowned after defeating Ensign Ed 
Austin in three sets. Austin who represented the Pacific 
Fleet, lost three sets in a row 6-2, 6-2, 6-1. Another 
trophy for Saint Albans was Raskind winning the 
doubles championship. 

The tennis champion had to fly by helicopter to and 
from Newport for the All Navy Matches, Also being 
the only Ophthalmologist serving at St. Albans, Lt. 
Raskind was unable to enter the Inter-Service Tourney. 

LT Raskind, who is assigned to the Eye Clinic, swept 
through the District matches, mowing down all oppo- 
nents with his sensational play. He repeated the same 
feat in the North Atlantic Regional matches. In win- 
ning the title he encountered the cream of the Navy's 
tennis world. 

Born in New York City it 1934, LT Raskind started 
his tennis career at the age of 13. While attending 
Horace Mann High School, in 1950, he won the Eastern 
Inter-Scholastic Championship. He has also won the 
New York State title playing in the National Tennis 
Championships at Forest Hills, Long Island. 

After graduating from Horace Mann High School, 
he entered Yale University, where he was captain of the 
tennis team. Upon graduating from Yale he entered 
the University of Rochester Medical School where he 
received his M.D. degree. LT Raskind is the son of 
Dr. David M. Raskind, of Forest Hills, Long Island. 
—From St. Albans Naval Hospital NEWS 5(7): 1 and 
3, September 1964. 



YELLOW FEVER VACCINATIONS 

The Washington Heights Health Center of New York 
City offers free yellow fever vaccinations for travelers, 



supplementing the free inoculations available at the 
U. S. Public Health Service clinic in downtown Man- 
hattan.— Public Health Reports 78(12): 1060, Decem- 
ber 1963. 



U.S. NAVY MEDICAL NEWS LETTER 




DENTAL SECTION 



SPECIALIZATION IN DENTISTRY 



Excerpts from the Principles of Specialization in Dentistry which were adopted at the 
51st Annual Session of the FD1* Stockholm, Sweden 1963. 



Purpose of Principles. The purpose of these princi- 
ples is to provide recommended standards on the defi- 
nition, recognition, education and organization of 
specialists in dentistry. They may also provide guide 
lines for the orderly growth of specialization in coun- 
tries which "wish to develop or expand a formal 
programme. 

Use of Term "Specialists". The use of the term 
"specialist" does not have universal acceptance in the 
dental profession. The claim to professional superiority 
which is implied in the word has caused a search for 
an equivalent which would not appear to erect hier- 
archical values among those who render dental health 
service. The general recognition by the public of the 
term "specialist," however, may suggest its continued 
use until more acceptable terminology is available and 
accepted through popular and professional usage. 

The dental profession should determine as early as 
possible in its national programme, the term by which 
it wishes to identify those who fulfill the functions of 
those who are presently termed specialists. 

General Practice and Specialization. The general 
practitioner in dentistry is permitted to perform all of 
the professional acts which are authorized in the statute 
under which he is qualified or licensed. The specialist 
has the same basic legal status but must also demon- 
strate a greater degree of competence in a particular 
area of dental practice. Such competence can only flow 
from education, training and experience beyond that of 
the general practitioner. Specialization, therefore, is 
deemed to be a supplement to, and not a replacement 
of, general practice in dentistry. 

Objective of Specialization. The basic objective of a 
programme for specialization in dentistry is to identify 
to the public and to the profession the practitioner who 



has special competence in rendering an exceptional 
service to the patient. A programme of specialization 
may also be useful in stimulating organization, educa- 
tion and research in a particular area of dentistry. 
Specialization should not he utilized to foster a reduc- 
tion in the educational requirements and responsibility 
of the general practitioner. Nor should it be used to 
provide better status for the practitioner, or to facili- 
tate economic benefits which exceed the value of the 
service rendered to the patient. 

Recognition of Specialists. A programme for special- 
ization should involve some mechanism for recognizing 
the specialist and for identifying him to the public and 
to the profession. Two of the more common methods 
are: (1) recognition by the profession through its 
national organization; (2) recognition by legal statute 
through a governmental or academic body. 

Recognition by Profession. Recognition of the spe- 
cialist by the profession produces greater flexibility in 
meeting needs as they are determined by members of 
the profession. Since this method is voluntary in na- 
ture, it can invoke no sanctions, except those of an 
ethical nature, thus making discipline and enforcement 
more difficult. 

The profession may recognize specialists by: (I) de- 
fining the areas of dental practice in which specializa- 
tion will be recognized; <2) establishing the educational 
and experience requirements for practice in a special 
area; (3) establishing boards which validate educational 
and experience qualifications and administer the exam- 
inations for entrance into specialist status; (4) awarding 
certificates, through the specialist examining boards, 
to those who have successfully completed the require- 
ments and achieved the status of a "diplomate" who is 
qualified to practice in a special area. 



'0 



U.S. NAVY MEDICAL NEWS LETTER 



Recognition by Legal Statute. Recognition by legal 
statute provides immediate means for discipline and 
enforcement in the area of specialty practice. Legal 
recognition may not always be entirely consistent with 
the wishes of the profession and may be more difficult 
of amendment to meet changing needs. Administration 
and enforcement are subject to the control of the legally 
established agency which may not always be wholly 
aware of the professional problems that are involved. 
Under the statutory method of recognition, the areas 
of special practice, the requirements for specialization 
and modes of enforcement are set down by law and 
are administered by an appropriate governmental or 
academic agency to which authority is assigned. 

Definition of Areas of Practice. The definition and 
number of the areas of dentistry in which specialized 
practice is permitted will vary in accordance with needs 
and traditions. The definition of special areas of prac- 
tice in dentistry depends upon a logical separation of 
dental services into categories characterized by funda- 
mentally different objectives and distinct biological and 
physical approaches to diagnosis, treatment and pre- 
vention of disease, involving knowledge and skills be- 
yond those which can normally be expected for the gen- 
eral practice of dentistry. 

The following criteria may be helpful in identifying 
areas which may be susceptible to the development of 
specialized practice: 

1. The area should have importance in the protec- 
tion of the health and welfare of the patient; 

2. The area should be one in which the general 
practitioner has frequent need to refer patients in order 
to provide an exceptional service to the patient; 

3. The area should be one that calls for special 
knowledge and skills requiring intensive study and ex- 
tended clinical and laboratory experience beyond under- 
graduate dental training in order to perform services 
of difficult or unusual nature; 

4. The area should be one in which there is evidence 
that there is need for the full time services of the spe- 
cialist to meet a particular public need; 

5. The area should be one in which a sufficient num- 
ber of educational institutions provide formal courses 
which wilt qualify practitioners in the special area; 

6. The area should be capable of a precise definition 
of its limits so as to establish the qualifications required 
for practice in the special area and to restrict the 
specialist to rendering services in a well defined field. 

The number of special areas in which practice is 
authorized requires extended consideration in order to 
avoid fractioning the services of the profession into 
inadequate and meaningless segments which will not 
permit the best service to the patient. 

In initiating or developing a programme for special- 
ization, the designation of a limited number of special 
areas appears to be desirable. Two areas are generally 



recognized as meeting all of the major requirements 
for designation as special areas of practice: oral sur- 
gery and orthodontics. Initial recognition of these two 
areas will permit the accumulation of experience which 
may eventually lead to the approval of other special 
areas as need is demonstrated. 

Specialty Organizations. The development of organi- 
zations devoted to the interests of special areas of den- 
tal practice should be encouraged on the basis of a 
well-defined and close relation to the profession and 
national dental association. Such organizations can 
assist in developing knowledge and research in the spe- 
cial area; assist in meeting the specialized needs of its 
members, and encourage the development of higher 
standards of education and practice for the area. 

Conclusion. Programmes for specialization in den- 
tistry should be developed on a planned basis by giving 
appropriate weight to the need, the stage of professional 
development and related social and economic factors 
in a given country. A well organized and controlled 
programme for specialization can assist in providing 
a better service to the patient and thus make its contri- 
bution to the health of the nation. 
* Federation Dentaire Internationale. 



BRIEF HISTORY OF THE RUBBER DAM 



Harry J. Winner DDS, Dental Survey 40(10): 76-85, 
October 1964. 



Since 1964 is the 100th anniversary of the introduc- 
tion of the rubber dam, it would seem appropriate to 
learn something about the man whose ingenuity made 
Dam Dentistry possible, the struggle for recognition of 
its value in restorative dentistry and the controversy that 
raged over who really gave birth to the idea of the rub- 
ber dam. It is hoped that the recognition of the 100 
years of faithful service given by the rubber dam will 
reawaken today's practitioners to the value of its use 
in modern dentistry. 

Excerpts from a meeting of the Connecticut Valley 
Dental Society reported in the Canada Journal of Dental 
Science, Vol. IV, 1877-1879, reports the history of the 
discovery of the rubber dam as told by Dr. Barnum: 

"At the time the idea of the rubber dam dawned upon 
my mind, I was practicing in Monticello, Sullivan 
County, New York. It was the result of much persecu- 
tion from the inroads of saliva, I had spent many an 
hour, weary and distracted, battling against its incur- 
sions. Many a sleepless night had I over sad failures 
. . . with the one absorbing question ever before me 
unanswered, 'How shall I keep the cavities dry?' 



U.S. NAVY MEDICAL NEWS LETTER 



11 



"The answer came; and may I say that I was led to 
the discovery in this manner. In plugging cavities near 
the gum, I had adapted theuuse of rubber rings or liga- 
tures around the necks of the teeth, crowding them well 
up under the free margins. . . . Also in plugging the up- 
per teeth 1 placed a piece of oilskin beneath the napkin, 
it preventing the accumulation of moisture in the floor 
of the mouth from being taken up and soaking the 
napkin. These two things led me to the thought, 'Can 
I join the ring of rubber to the apron of oilskin?' 

"In the fall of 1863, I procured some sheet or rubber 
cloth for the same purpose I had been using the oilskin. 
How soon after that the idea of cutting a hole in the 
rubber and slipping it over the tooth came to me, I can- 
not call it to mind; but this I have well fixed, that on 
the fifteenth day of March, 1864, a case presented itself 
of a cavity in a lower molar, standing alone, on the left 
side in a mouth as wet — well, as water gushing from 
every duct could make it. 

"In a sort of half-desperate way, and partly to try 
the new idea, I cut a hole in my napkin protector — and 
over the tooth it went. There I found I had the ring of 



rubber and an apron combined! There was the rubber 
dam! And from that time until it was presented to the 
profession the following summer I developed, step by 
step, many of its important points." 

Although Dr. Barnum originated the idea of the rub- 
ber dam, his uncle, Dr. J. W. Clewes, introduced it 
(giving credit to Dr. Barnum) to the profession at a 
meeting of the New York Dental Society in June 1864. 

The statement by A. H. Brockway as it appeared in 
a transcript of the New York Odontological Society is 
not inappropriate today, even though it was made in 
1885; 

"It is not too much to say that this device (rubber 
dam), simple as it is, has been one of the most im- 
portant and valuable contributions to operative dentis- 
try that have thus far been made. By its proper use not 
only is the discomfort of the patient lessened, but the 
mind of the dentist being relieved of all anxiety regard- 
ing the encroaching fluids, and his hands from the nec- 
essity of holding anything in place, a much higher 
quality of operations is possible than could otherwise 
be attained." 



A STUDY OF THE USE OF HOME 
RELINERS IN DENTURES 



Craig R. Means BS DDS MSc, Howard University, 
College of Dentistry. Washington, D.C., J Pros Den. 
14(4): 623-634, July-August 1964. 



The author reports a study of 29 patients who had 
added or applied home liner materials to their den- 
tures. The results are in agreement with opinions held 
by The Council on Dental Research and the Council 
on Dental Therapeutics of the American Dental Associ- 
ation, that the promotion of such products is not in the 
public interest and that the use of them presents many 
hazards to the health of the patient. 

In several of the dentures, the author noted that as 
many as seven layers of reline material could be 
counted. Findings were that the reliners contributed 
to the imbalance of the dentures, loss of retention and 
stability, overextension of the borders, collection of 
food and other debris upon the tissue surface of the 
denture, development of pseudo-epitheliomatous hy- 
perplasias, and irritations which could lead to pre- 
cancerous or cancerous lesions. 

The article stresses the responsibility of the dental 
profession in educating the patient completely in the 
use and care of dentures and the need for periodic pro- 
fessional treatment after the dentures are placed. 



OROPHARYNGEAL CANCER IN BHOPAL 



/ Indian Med Assoc 42: 519-521, June 1964. JAMA 
189(12): 979, Sept 21, 1964. 

V. Agarwal MD and M. M. Arora MD, who teach 
at the Gandhi Medical College in Bhopal, India, report 
that of all malignant diseases found in Bhopal, 40.5% 
are cases of oropharyngeal cancer. A total of 200 
cases were seen by the authors during the last few 
years. The highest incidence of this disease is found 
in the 4th and 5th decades of life. Since all patients 
seen by the authors had a history of chewing tobacco, 
the authors feel that this might be an important etiolog- 
ical factor in the causation of oropharyngeal cancer. 



DIETARY SELECTIONS OF PERSONS WITH 
NATURAL AND ARTIFICIAL TEETH 

A. Albert Yurkstas, DS MS DMD, and W. H. Emerson, 
DMD. Tufts University School of Dental Medicine, 
Boston, Massachusetts. J Pros Den 14(4): 695-697. 
July-August 1964. 

The authors cite a study of the diet of 28 young 
adults with natural dentitions as compared with that of 
a similar number of subjects wearing dentures who 
were selected at random. 

The results indicated that denture wearers eat more 
of the following foods: Cheese, processed fruit, fish, 
raw fruit, eggs, cereals, breads and cooked vegetables. 



12 



U.S. NAVY MEDICAL NEWS LETTER 



whereas those with natural dentitions consume more 
meat, soup, desserts, beverages, raw vegetables, sand- 
wiches and salads. Of interest is the fact that those 
with natural dentitions ate over twice as many sand- 
wiches and five times as many salads as those with 
dentures. Although the study showed that both groups 
ate nearly equal amounts of bread, cooked vegetables, 
and meats, there was some selection within food items 
on the basis of food form. 



The clinical manifestations of the study point to the 
fact that new denture patients especially should be 
urged to prepare the basic nutritional foods in a form 
that is easily comminuted. To this end the dentist has 
a prime responsibility in providing a list of especially 
prepared foods that not only will assure an adequate 
diet, but also ease the patient over the transitional 
period of adjustment. 



PERSONNEL AND PROFESSIONAL NOTES 



Cement-Alloy Program. From time to time, the Dental 
Division receives comments relative to the Cement- 
Alloy Program instituted several years ago at the Naval 
Training Center, Great Lakes, Illinois. As a matter of 
general interest, the following is quoted from a letter 
recently received at the Bureau: 

"On 19 August 1964, a young sailor came into my 
office for a dental examination. On 12 July 1963, the 
following cement-alloys were placed at Great Lakes: 
2-O-F, 3-OL, 31-O-F; on 15 July 1963, 5-MOD, 14-0, 
15-OF. All were still in good service except that 
placed in tooth #14, which had been replaced at San 
Juan with an MOD amalgam. I have been using zinc 
oxide-alloy fillings in children's teeth with much suc- 
cess so far. The material has a sedative quality, sets up 
hard, manipulates well and seems to hold up well." 
— S/LCDR John F. Lessig, DC USN, U.S. 

Naval Radio Station (T), Ft. Allen, 

Puerto Rico 

Foreign Medical Officers Visit NDC Norfolk. Thirteen 
foreign military medical officers from twelve foreign 
countries who are undergoing a fourteen-week training 
course, administered by the U.S. Naval Medical School, 
Bethesda, Maryland, recently visited the U.S. Naval 
Dental Clinic, Norfolk, Virginia. They were members 
of the 7th class conducted by the Naval Medical School 
Foreign Officer Department. CAPT W. B. Lett, DC 
USN, Commanding Officer (Acting), CAPT J. P. 
Arthur, DC USN, and CAPT L. F. Abel, DC USN, of 
U.S. Naval Dental Clinic, Norfolk, Virginia, and CAPT 
E. H. Joy, MC USN, Officer-in-Charge, U.S. Naval 
Preventive Medicine Unit #2, Norfolk, Virginia, we?e 
joint hosts. 

Touring the area were CAPT Aureliano Rey Merodio, 
Argentina; CAPT Nelson Hora Oliveira and CAPT 
Gilson Ferreira de Almeida, Brazil; CDR Tso-an-Chen, 
China; LT Mariano Maura Reyes, Dominican Republic; 
CDR Ralf von Gregory, Germany; CAPT Konstantinos 
Rizos, Greece; CDR Jalal Hamidi, Iran; CDR Antonino 



Aliquo, Italy; CAPT Tong Pil Choe, Korea; CDR Wes- 
sel R. Vermeer, Netherlands; LCDR J. Pico Brotons, 
Spain; and LCDR Dang Tat Khiem, Vietnam. CAPT 
J. H. Stover Jr., MC USN, Commanding Officer, U.S. 
Naval Medical School, Bethesda, Maryland and CAPT 
J. M. Hirst, MSC USN, Director of the Training Course 
at the Naval Medical School, were in charge of the tour. 

Participation Urged in Science Fair Activities. This 
is the season for junior high and high school students 
to select science fair studies. Members of the Dental 
Corps are encouraged to assist students interested in 
dental health and dental science in their projects. The 
American Dental Association makes the following ma- 
terial available to guide students: Frontiers in Dental 
Science (50(f) from Scholastic Book Services, 904 
Sylvan Ave., Englewood Cliffs, New Jersey; Dental 
Projects for High School Science Students (25^ for 
single copy; 20^ each for 10 or more) from Science 
Service, and ADA Catalog describing dental health lit- 
erature, information and films on career opportunities 
in dentistry (single copy on request). Write: Dr. Sholom 
Pearlman, ADA, 222 East Superior Street, Chicago, 
Illinois. 

Navy Dentist Presents Essay in Mexico. CDR Walter 
N. Johnson, DC USN, U.S. Naval Dental Clinic, Camp 
Pendleton, California, presented as essay entitled, 
"Current Concepts of Periodontal Therapy," before 
the Seventh Annual National Convention of Oral Sur- 
geons of Mexico, held 31 October through 4 November 
1964, in Uruapan, Michoacan, Republic of Mexico. 
Naval Dental Reserve Key Personnel Changes at 
BUMED. CAPT Robert F. Tuck, DC USNR, Com- 
manding Officer, U.S. Naval Reserve Company 9-3 
(Chicago) for sixteen years, was recently called to ac- 
tive duty to serve as Head, Reserve Branch, Dental 
Division, Bureau of medicine and Surgery. In this 
capacity, he relieves CAPT Harry J. Wunderlich, DC 
USNR, who has held this position since June 1957. 



U.S. NAVY MEDICAL NEWS LETTER 



13 



CAPT Wunderlich's next duty station has not been 
determined as of this writing. CAPT Tuck has been 
active in the Naval Dental Reserve since his release 
from active duty in 1945. In addition to annual active 
duty for training, he recently attended the Naval War 
College at Newport, Rhode Island, and has served on 
a Reserve Officer selection board. He has served as 
President of the Chicago Alumni Chapter, Xi Psi Phi; 



the Illinois Section, American College of Dentists; and 
the Chicago Dental Society. He is also a member of 
the Odontographic Society of Chicago; Academy of 
General Dentistry, and the Illinois State Dental Society, 
of which he has served as delegate to the American 
Dental Association. CAPT Robert C. McDonald, DC 
USNR, relieved CAPT Tuck as Commanding Officer, 
U.S. Naval Reserve Company 9-3. 




OCCUPATIONAL MEDICINE 



HEAT ILLNESS AND SOME RELATED PROBLEMS 



A. W. El Halawani MD, Saudi Arabia, World Health Organization, WHO CHRONICLE, 
18(8): 288-298, Aug 1964. 



Since the word "heat" in the term "heat illness" is 
often assumed to refer solely or mainly to environ- 
mental or external heat, it must be stressed that the 
really crucial factor is the sum of endogenous (meta- 
bolic) and external heat. In hot surroundings, men are 
particularly liable to suffer heat illness if they are 
exercising or working; and probably nowhere in the 
world are natural climates too hot to be endured by 
resting men. The basis of heat illness is disordered 
physiology resulting from the function of thermoregula- 
tion, and only perhaps in heat stroke or in heat hyper- 
pyrexia can it be said that thermoregulation has failed; 
in other words, the heat disorders are byproducts of 
active and almost invariably successful thermoregula- 
tion. 

The nomenclature and classification of the heat dis- 
orders are at present in an unsatisfactory state. The 
International Classification of Diseases contains the 
now obsolete term "sunstroke", and lists together the 
effects of heat and insolation, so that it includes "sun- 
burn"; in addition, it has been outdated by growing 
understanding of the pathogenesis of heat exhaustion, 
and it does not include the syndrome of anhidrotic heat 
exhaustion identified in troops in the Second World 



War. The revision of the International Classification 
will, without doubt, take the various criticisms of the 
classification of heat disorders into account. 

From a clinical point of view, the heat disorders can 
be listed and defined as follows; 

1. Heat syncope (heat collapse; exercise-induced 
heat exhaustion) : syncope or sensations of giddiness or 
acute physical fatigue during exposure to heat, result- 
ing from peripheral vasodilatation, a collapse in vaso- 
motor tone, venous pooling, hypotension, and cerebral 
anoxia, and occurring in the absence of observable 
water and salt depletion. 

2. Heat edema: slight edema of the extremities and 
particularly of the feet and ankles, usually limited in 
occurrence and duration to the first week or ten days 
of exposure of the affected individual to truly tropical 
heat. 

3. Water-depletion heat exhaustion: progressive 
water depletion due to inadequate replacement of water 
losses in prolonged sweating, characterized by thirst, 
fatigue, giddiness, oliguria, fever, and, in the advanced 
stages delirium and death. Since in normal circum- 
stances the onset of thirst prevents clinically overt water 
depletion, the disorder is rare and occurs when water 



14 



U.S. NAVY MEDICAL NEWS LETTER 



is in seriously short supply, or when there are contribut- 
ing factors such as vomiting or diarrhoea. 

4. Salt-depletion heat exhaustion (heat exhaustion 
type I) : progressive salt depletion due to inadequate 
replacement of salt losses in prolonged and heavy 
sweating, characterized by fatigue, nausea, vomiting, 
giddiness, muscle cramps, and, in the late stages, circu- 
latory failure. The plasma levels of sodium and chloride 
are below average, and in successive urine samples be- 
fore treatment sodium chloride is consistently negligible 
or absent. 

5. Heat cramps (mill cramps; miner's, stoker's, 
cane cutter's, or fireman's cramps) : painful spasms 
of voluntary muscles following hard physical work, 
prolonged thermal sweating, and the drinking of large 
amounts of unsalted water. Heat cramps often have 
no associated symptoms, and differ probably only in 
this respect from the muscle cramps seen in salt- 
depletion heat exhaustion. 

6. Prickly heat (miliaria rubra; lichen tropicus; 
heat rash) : an erythematous papulovesicular rash 
accompanied by pricking or tingling sensations, en- 
countered only in circumstances which provoke pro- 
longed thermal sweating and commonest in humid 
environments where the skin is constantly wetted by 
unevaporated sweat. 

7. Anhidrotic heat exhaustion (thermogenic anhidro- 
sis; tropical anhidrotic asthenia; heat exhaustion type 
II) : a state of exhaustion and heat intolerance affecting 
men exposed for several months to a hot climate, ac- 
companied by the appearance of numerous discrete 
vesicles (miliaria profunda, or mammillaria) in the 
skin mainly of the trunk and proximal parts of the 
limbs, and by diminution or absence of sweating 
(anhidrosis) in the areas affected by the rash. The dis- 
order was observed in troops during the Second World 
War, but apparently few servicemen suffer from it in 
peacetime conditions, while civilians scarcely figure in 
the literature on the subject. 

8. Heat stroke and heat hyperpyrexia: heat stroke 
is a state of thermoregulatory failure of usually sudden 
onset, following exposure to very high external tem- 
peratures or strenuous exercise in less severe heat, 
characterized in its classical form by disturbance of 
the central nervous system, generalized anhidrosis, and 
a rectal temperature in the acute stage above 40.6° C 
(105° F). It is frequently fatal. Sweating in the pres- 
ence of coma and hyperpyrexia is an uncommon variant 
reported recently. 

Heat hyperpyrexia differs from heat stroke in that 
the patient is conscious and rational, and sweating may 
be present; the rectal temperature is above 40.6° C 
(105° F), but tends to be lower than in heat stroke. 

Clinical recognition of another entity — acute heat 
fatigue — may possibly be justified; this is a deteriora- 
tion in efficiency observed when men engaged in skilled 
tasks are exposed to very high ambient temperatures. 



The effect is particularly noticeable in those who find 
their job mentally exacting even in thermally com- 
fortable surroundings. This "disorder" is far more 
relevant to industrial than to natural climates, and the 
experimental evidence for it relates mainly to various 
reaction-time and visual-vigilance tests. 

Finally, some reference should be made to tropical 
fatigue, deterioration, or neurasthenia. It has long 
been argued that, as a result of the prevailing heat or 
humidity, immigrants to the tropics from cooler coun- 
tries are apt to suffer a variety of symptoms such as 
lassitude, reduced efficiency and morale, or even acute 
anxiety states, all lumped together as expressions of 
nervous debility. The present majority opinion is that 
there is no specially tropical form of neurasthenia, and 
that, if environmental in origin, symptoms correctly 
referable to neurasthenia arise from isolation, monot- 
ony, and similar dissatisfactions common to small 
expatriate communities anywhere in the world. Fatigue 
is thought to be the best available word to describe the 
impaired efficiency, inability to concentrate, and death 
of ambition claimed by some immigrants (and some 
observers) to be the result of living in hot climates; and 
the importance of climatic heat or humidity in the 
causation of these phenomena is not yet clearly estab- 
lished. This is a problem which merits continued study; 
but the current industrial development of tropical 
countries both invites and requires a wholly objective 
investigation of the working efficiency of home-bred 
and home-based Asian, African, and other populations, 
along the lines being taken in the Sahara. However, 
adaptation in the sense of performance is less relevant 
than the acute heat disorders to the medical problems 
of the Mecca Pilgrimage. 

The Etiology of the Heat Disorders. The elements 
and events which culminate in heat disorders can be 
divided into two main groups. The first comprises the 
prevailing air temperature, humidity, movement, and 
radiant heat, energy expenditure and therefore body 
heat production in the circumstances in question, and 
the heat exchanges between the environment and the 
individuals exposed; these are all measureable and 
susceptible, up to a point, of arithmetic treatment and 
analysis. The second group concerns the essentially 
human elements, namely individual variations in re- 
sponse to heat in degree of acclimatization, behaviour, 
age, build, clothing, physical fitness, and health, and 
other occasionally critical factors; these are seldom 
measurable, particularly in a civilian population se- 
lected, for example, as in the Mecca Pilgrimage, solely 
on the basis of religious belief. 

A common preliminary approach to a study of the 
effect of environmental temperatures is to use standard 
meteorological data by which to compare the incidence 
of heat disorders in the climate in question with the 
recorded incidence in apparently similar circumstances. 
Herein lies the first barrier to progress, for the tem- 



U.S. NAVY MEDICAL NEWS LETTER 



15 



peratures prevailing in the area where heat illness is 
occurring might differ significantly from the data sup- 
plied by the nearest appropriate meteorological station; 
furthermore, our knowledge of the circumstances in 
which heat disorders are a problem is based increas- 
ingly on a far more detailed study of the environment 
than is provided by the usual methods of reporting 
meteorological data. A plea has been made recently 
for meteorological data presented in terms of means 
and standard deviations therefrom, and better still, for 
the following information to be made available for con- 
ditions by day: (a) the average dry-bulb temperature 
for the hottest hour of the day; (b) the average relative 
humidity for the hottest hour of the day; (c) the wind._ 
force over the period 11 a.m. to 5 p.m.; and (d) the 
presence of solar radiation, or preferably the average 
black-globe temperature in direct sunlight, for the hot- 
test hour of the day. 

In certain limited and more or less unvarying circum- 
stances, the measurement of one single component of 
the climate may serve as a practical guide for the pre- 
diction of heat illness; easily the best example is that 
provided by industrial and particularly mining environ- 
ments, where heat stroke is known to occur when men 
work in saturated air at a wet -bulb temperature of or 
above 30° C (86° F). If, however, the limiting environ- 
mental temperatures above which heat disorders occur 
are ever to be identified with reasonable precision and 
in a way suitable for "universal application, a measure 
of one single component of the climates concerned is 
not enough. This applies equally to the identification 
of the upper limit of temperatures in which men feel 
comfortable or can work without objective evidence of 
dangerous or cumulative physiological strain; and many 
attempts have been made to integrate into a single in- 
dex the effects of two or more of the several factors 
that influence heat exchanges between man and his en- 
vironment. As a result, various heat stress indices 
have been elaborated and described. They include the 
effective Temperature (ET) Scale, the Wet Bulb Globe 
Temperature (WBGT) Index, the Cumulative Discom- 
fort Index (Cum. DI), the Predicted Four-Hour Sweat 
Rate (P 4 SR), and the Heat Stress Index (HSI). 

Of these indices of heat stress, the P 4 SR is generally 
regarded as the best. Young, fit, and acclimatized men 
can tolerate hard work in climates corresponding to 
P 4 SR values of up to 4.5, while for the unacclimatized 
the upper limit is probably not more than 3. Above 
these limits, an increasing number of men find the 
conditions beyond their endurance, and (from the 
scanty evidence available) heat disorders begin to be 
a significant problem. The identification of the upper 
limits of environmental heat compatible with body- 
temperature balance at various rates of work or exer- 
cise is an approach which has been studied in relation 
to the mining industry and appears to hold some hope 



for the prediction of heat" stroke in severe but relatively 
unchanging circumstances. 

It is tempting to view heat stroke as the result solely 
of heat loads which cannot be dissipated even when the 
body's heat-losing mechanisms are in good shape and 
fully operative. In other words, the condition may be 
the inevitable result of intolerable combinations of 
environmental and endogenous heat. Heat stroke, how- 
ever, is by no means confined to such obviously danger- 
ous circumstances. At a lower level of heat stress, for 
example, with a P 4 SR index beginning to rise above 
4.5, it is hardly possible to say more than that an in- 
creasing number of men will find conditions beyond 
their endurance, mainly because adequate information 
on the point is lacking, but also because there can never 
be a wholly accurate method of forecasting the heat 
disorders. In the' individual case, be it of heat stroke 
or of heat exhaustion, individual factors are implicated 
to a varying degree. 

Inadequate acclimatization to the prevailing heat is 
perhaps the most important of these. Of British troops 
entering Kuwait at short notice in the summer of 1961, 
a contingent straight from the United Kingdom suffered 
many heat casualties, whereas a contingent sent from 
nearby Sharja in the Trucial Oman had none at all. The 
influence of acclimatization is hardly surprising, since 
it greatly relieves the initial strains put upon thermo- 
regulation, fluid balance, and the circulation. It may 
be, however, that some of the casualties among trav- 
elers shortly after they enter the heat are due to indi- 
vidual susceptibility, in terms perhaps of an inherent 
weakness in thermoregulation or in water and electro- 
lyte balance. There is no evidence to support this, but 
the generally low incidence of the heat disorders in 
most natural and many industrial environments is 
suggestive. 

When civilian populations of widely ranging age are 
exposed to unaccustomed heat, the elderly are the most 
commonly and severely affected. During heat waves in 
Chicago, Cincinnati, and St. Louis, 80% of those who 
suffered from one or other of the heat disorders were 
above 40 years of age. As might be expected, heat 
stroke in middle and old age is frequently associated 
with degenerative cardiovascular disease, particularly 
arteriosclerosis, hypertension, and myocardial ischae- 
mia; and since (on the few occasions it has been 
attempted) electrocardiography in young men with heat 
stroke has shown impressive degrees of myocardial 
damage, it may be that degenerative cardiovascular 
disease influences survival as well as susceptibility. 

Infants are also peculiarly prone to heat stroke, ap- 
parently more because of their vulnerability to water 
depletion than because of any primary defect of thermo- 
regulation. Age apart, general health can be important, 
particularly in relation to fluid and electrolyte losses in 
intercurrent diarrhoea or vomiting, the effect of atopic 
eczema or other extensive skin disease on the integrity 



16 



U.S. NAVY MEDICAL NEWS LETTER 



of the sweating mechanism, and the possible influence 
of febrile infections on thermoregulation. Precisely to 
what extent fever interferes with thermoregulation in 
hot surroundings is problematic. It seems bound to 
raise the body "thermostat" level and indeed has been 
shown to do so, and the combined effect of the fever, 
physical exercise, and environmental heat might be 
dangerous; in addition, pyrogenic agents such as typhoid 
vaccine have been shown to interfere with the produc- 
tion of thermal sweat. A point worth remembering 
in this context is that the belladonna alkaloids, such 
as atropine, hyoscine, and scopolamine, and to a lesser 
extent certain antihistamine drugs depress thermal 
sweating, and from time to time atropine or one of its 
analogues is implicated as having contributed to a case 
of fatal heat stroke. 

Other factors which deserve mention are build and 
sex. Obese individuals are at a special risk of heat 
illness, and this has been attributed to their difficulties 
in heat dissipation on account of the greater ratio of 
body weight to surface area. The influence of sex is 
not clear, simply because men and women are seldom 
exposed together to the same conditions of heat and 
work; the Mecca Pilgrimage figures show that heat dis- 
orders are twice as prevalent in men as in women, but 
the sex ratio of the pilgrims has not been ascertained; 
an opportunity appears to exist for more information on 
this point. . A recent study in the USA has shown that 
women become acclimatised to heat in much the same 
way as do men, but with some differences suggesting 
that heat dissipation from the body might be more 
difficult than in men. 

In addition to constitutional variations between indi- 
viduals, there are important differences in the way in 
which they behave when exposed to heat, particularly 
in respect to the clothing they wear and of how effec- 
tively they replace fluid and electrolyte losses in sweat. 
It is clear, however, that clothing is not a problem on 
the Mecca Pilgrimage. Clothing interferes to some ex- 
tent with the evaporation of sweat, although not to a 
significant degree in hot and dry climates, while white 
clothing has been shown to reduce by half the solar heat 
load. This means that in Arafat and Mena white and 
loosely-fitting garments of a permeable material are 
protective to a degree which more than offsets any 
hindrance to sweat evaporation. 

So far as the replacement of water and electrolytes 
lost in sweat is concerned, experience has. taught that 
generalizations are hazardous. This is particularly true 
of salt requirements, a subject in which conclusions 
from limited observations have masqueraded too often 
as universally applicable facts. The facts are that 
some ethnic groups subsist happily on diets con- 
taining practically no salt; that most European and 
American expatriates living in the tropics take, and 
need, no more salt than at home; that even in quite 
arduous conditions of exercise and environmental heat, 



troops in India and in Israelis was pointed out during 
the technical discussions at the twelfth session of the 
WHO Regional Committee for the Eastern Mediter- 
ranean) have shown no need of extra salt; and that salt- 
depletion heat exhaustion is a well-documented and in 
some circumstances common disorder. The explana- 
tion of these facts appears to lie in salt-conservation 
mechanisms which adjust loss to intake, and which can 
reduce urinary sodium and (in hot surroundings) sweat 
sodium loss to negligible levels. If salt intake is high, 
urine and sweat sodium levels are correspondingly so, 
and it is in just this state of favourable balance that the 
average European enters unaccustomed heat and be- 
gins to sweat; if thereafter the heat is severe and the 
going hard, and if water losses in the sweat are re- 
placed, salt depletion may reach clinical significance 
before conservation mechanisms are fully operative. 
This suggests that salt-depletion heat exhaustion is 
primarily a disorder of the unacclimatized, which indeed 
it is. When a sufficiently high salt intake is main- 
tained, the fall in sweat sodium that usually accom- 
panies heat acclimatization does not occur; it is de- 
pendent therefore on the stimulus of a negative salt 
balance, and it has long been believed that aldosterone 
is the mediating agent. The question seems to have 
been settled by recent work showing that the sodium 
content of drug-induced eccrine sweat is diminished by 
the administration of aldosterone. The facts concern- 
ing the salt requirements of Mecca pilgrims must await 
detailed and laboratory identification of the types of 
heat exhaustion encountered, and of the groups (if any) 
in which clinically overt salt depletion occurs. Pil- 
grims from Europe may be affected, and possibly also 
tribesmen from the interior of Saudi Arabia if they are 
accumstomed to brackish water and drink unsalted 
water while in Mecca; there is a precedent in Kuwait 
for this situation, as was also pointed out in the tech- 
nical discussions at the twelfth session of the WHO 
Regional Committee for the Eastern Mediterranean. 
The one generalization which seems safe and of univer- 
sal application is that for each set of circumstances 
there is a minimum and obligatory intake of salt. 

The problem of water depletion on the Mecca Pil- 
grimage has evidently been, tackled by the Saudi 
Arabian Government in a commendably realistic way. 
If circumstances permit, water requirements are regu- 
lated by water-craving or thirst to the extent that clini- 
cally overt water depletion rarely occurs, whereas there 
is in man no salt-craving comparable to that found in 
some animals. In terms, however, of habit rather 
than of health or survival, the water intakes of indi- 
viduals vary considerably. Variations in intake are 
readily observed in hot climates, particularly when 
the behaviour of groups at different stages of adjust- 
ment to the circumstances is compared. In the pro- 
cess we call heat acclimatization, the volume of sweat 
produced in response to a standard heat load increases; 



U.S. NAVY MEDICAL NEWS LETTER 



17 



and if substantial amounts of sweat are involved, it is 
clear that water intake may rise accordingly. On the 
other hand, permanent tropical residents appear to 
drink far less water than do newcomers, and this is, 
particularly true of desert environments in which water 
is scarce. It seems that long-term adaptation to water 
shortage, heat, or both greatly improves water econ- 
omy and thereby lowers water requirements. The 
mechanisms by which this is achieved are still obscure, 
but, so far as thermoregulation is concerned, it has 
been suggested that long-term acclimatization may 
bring a more even distribution of sweat over the body 
surface, and it seems possible also that sweat losses 
may become as little as they need be for adequate heat 
removal. Speculation apart, it is clear that among a 
population so diverse in origins and habits as the Mecca 
pilgrims water requirements must vary widely. During 
the fulfilment of the more strenuous of their religious 



rites, however, all the pilgrims seem liable to develop 
the phenomenon known as voluntary dehydration. 

It is well known that a mild degree of water deple- 
tion develops during work in hot surroundings, and is 
usually made good at mealtimes or in leisure hours. 
Voluntary dehydration is symptomless, but it is asso- 
ciated with increased heart rates and body temperatures 
and presumably therefore is better avoided if possible. 
The phenomenon is associated also with diminished 
sweating, although probably not to a degree significant 
in terms of thermoregulation. It has been shown in 
Bahrein that, unless palatable drinking fluids are within 
easy reach, voluntary dehydration persists indefinitely 
and must increase the risk of water-depletion heat ex- 
haustion occurring as a result of a hitch in water 
supplies, increased and sustained effort, or intercurrent 
diarrhoea. (To be continued) 



HUMAN RABIES— MINNESOTA 

The first case of human rabies reported for 1964 
occurred in a 10-year-old boy from Wabasha County, 
Minnesota. On August 5, 1964 the boy was bitten by a 
skunk on the right wrist and left index and fifth fingers, 
while sleeping in a tent. His brother, age 3 was also 
bitten on the wrist. The wounds were not clean punc- 
ture wounds but appeared to be chewed. 

Duck embryo vaccine was administered on the day 
of occurrence and a total of 14 daily doses were sub- 
sequently given. Both children were also given a booster 
dose of tetanus toxoid. 

On August 25, the 10-year-old boy noticed numbness 
of the right forearm. The next day he had fever and 
generalized myalgia. On August 27 his temperature 
was recorded as 101° F and he complained of a stiff 
neck. The following day he was admitted to a Roches- 
ter, Minnesota hospital because of ascending paralysis, 
hallucinations, incoordination, stiff neck, and fever to 
104° F. He did not convulse or salivate. Cerebro- 
spinal fluid examination revealed 124 cells, all lympho- 
cytes; the peripheral white blood count was 12,700. He 
expired on September 1 and an autopsy was performed. 
Fluorescent antibody tests on the boy's brain were 
negative. Six mice were inoculated with brain tissue 
from the patient on September 2. On September 16, 
one of the mice became paralyzed and was sacrificed. 

Negri bodies were demonstrated in the mouse brain 
by the Williams stain. The fluorescent antibody stain 
was also positive. The biting animal was not captured. 
(Reported by Dr. D. S. Fleming, Director, Division of 
Disease Prevention and Control, Minnesota State 
Health Department.) — From: Morbidity & Mortality 
Weekly Report, 13(38): 330, 25 Sept. 1964. 



ANTISMOKING DRUGS 

The recent U.S. Public Health Service publication on 
health hazards of cigarette smoking has stimulated wide- 
spread use of patented medications intended to curb the 
desire for smoking. 

Many aircrew members are taking these medications 
in the belief that they have no possible medical effects. 
Most of these preparations contain lobeline, a powerful 
drug which may have effects on the heart and conscious- 
ness. Flying personnel should be informed that the 
usual cautions against self-medication apply to all anti- 
smoking drugs. — U.S. Air Force Med Ser Jour, 

XV(III) : 29, March 1964. 

INTERNATIONAL CERTIFICATES OF 
VACCINATION 

Next to the passport, the most important document 
for foreign travel is the International Certificates of Vac- 
cination. Every day hundreds of world travelers who 
forgot this fact run into delays in quarantine. The 
reason: They fail to present a valid international cer- 
tificate of vaccination against smallpox. In the United 
States the certificate is published as Public Health Serv- 
ice form 731, "International Certificates of Vaccina- 
tion," revised June 1961. It is given out with the pass- 
port application. The certificate may also be obtained 
from local and State health departments or from offices 
of the U.S. Public Health Service. In addition, it may 
be purchased from the Superintendent of Documents, 
U.S. Government Printing Office, Washington, D. C. 
20402, at 10 cents a copy. Travel agencies and trans- 
portation companies wanting to provide the certificate 
as a service to their clients may purchase copies at 
$5.00 per hundred. 



18 



U.S. NAVY MEDICAL NEWS LETTER 



RESERVE SECTION 




NEW INDIVIDUAL DRILL PAY SCALES* 



These are the rates of pay for individual drills by Reservists effective from September 1 under the new 
pay law. The amounts shown for longer-service 0-2s and O-ls and marked by asterisks are payable only to officers 
credited with over four years' active enlisted service. An 0-3 credited with such service receives $22.21 at the 
"over 14 years" point instead of the $21.87 received by 0-3 without enlisted service. Pay of E-ls with less than 
four months remains $2.60. 






Pay Under Over Over Over Over Over Over Over 
Grade 2 yrs 2 3 4 6 8 10 12 

COMMISSIONED OFFICERS 



Over 


Over 


Over 


Over 


Over 


Over 


14 


16 


18 


20 


22 


26 



0-8 . 


. 34.84 


35.88 


36.73 


36.73 


36.73 


39.46 


39.46 


41.34 


41.34 


43.05 


44.93 


46.64 


48.52 




0-7 . 


. 28.94 


30.92 


30.92 


30.92 


32.29 


32.29 


34.17 


34.17 


35.88 


39.46 


42.20 








0-6 . 


. 21.44 


23.58 


25.11 


25.11 


25.11 


25.11 


25.11 


25.11 


25.97 


30.07 


31.60 


32.29 


34.17 


37.07 


0-5 . 


. 17.15 


20.16 


21.53 


21.53 


21.53 


21.53 


22.21 


23.40 


24.94 


26.82 


28.36 


29.21 


30.24 




0-4 . 


. 14.47 


17.60 


18.79 


18.79 


19.13 


19.99 


21.35 


22.55 


23.58 


24.60 


25.28 








0-3 . 


. 11.79 


15.03 


16.06 


17.77 


18.62 


19.30 


20.33 


21.35 


21.87 












0-2 . 


. 9.38 


12.81 


15.38 


15.89 


16.23 


16.74* 


17.60* 


18.28* 


18.79* 












0-1 . 


. 8.04 


10.25 


12.81 




13.67* 


14.18* 


14.69* 


15.20* 


15.89* 






















WARRANT OFFICERS 












W-4 


. 12.04 


14.69 


14.69 


15.03 


15.72 


16.40 


17.08 


18.28 


19.13 


19.82 


20.33 


21.01 


21.70 


23.40 


W-3 


. 10.95 


13.50 


13.50 


13.67 


13.84 


14.86 


15.72 


16.23 


16.74 


17.25 


17.77 


18.45 


19.13 


19.82 


W-2 


. 9.58 


11,79 


11.79 


12.13 


12.81 


13.50 


14.01 


14.52 


15.03 


15.55 


16.06 


16.57 


17.25 




W-l 


. 7.94 


10.42 


10.42 


11.28 


11.79 


12.30 


12.81 


13.33 


13.84 


14.35 


14.86 


15.38 
















ENLISTED PERSONNEL 












E-9 . 














14.86 


15.20 


15.55 


15.89 


16.23 


16.57 


17.43 


19.13 


E-8 . 












12.47 


12.81 


13.15 


13.50 


13.84 


14.18 


14.52 


15.38 


17.08 


E-7 . 


. 6.88 


9.40 


9.74 


10.08 


10.42 


10.76 


1 1.10 


11.45 


11.96 


12.30 


12.64 


12.81 


13.67 


15.38 


E-6 . 


. 5.86 


8.20 


8.54 


8.88 


9.23 


9.57 


9.91 


10.42 


10.76 


11.10 


11.28 








E-5 . 


. 4.84 


7.18 


7.52 


7.86 


8.37 


8.71 


9.05 


9.40 


9.57 












E-4 . 


. 4.08 


6.16 


6.49 


7.00 


7.35 




















E-3 . 


. 3.31 


4.95 


5.30 


5.64 






















E-2 . 


. 2.86 


4.10 


























E-l . 


. 2.77 


3.76 



























* Naval Reserve Association News, XH10): 2, 5, 8, October 1964. 



U.S. NAVY MEDICAL NEWS LETTER 



19 



NAVAL RESERVE SELECTION BOARD 
DATES ARE SET* 

Here is a lineup of boards which will meet next year 
to consider Naval Reserve officers for promotion 
selection : 

To Rear Admiral (Line): January 5 (includes con- 
tinuation). 

To Rear Admiral (Staff): January 5 (includes con- 
tinuation). 

To Captain (Line): January 12 (includes TARs). 

To Commander (Line): January 19 (includes Waves 
and TARS). 

To Captain (Staff): March 2 (includes continuation 
and TARs). 

To Commander (Staff): March 2 (includes Waves and 
TARs, same membership as Captain board). 

To Lieutenant Commander (Line): March 9 (includes 
Waves and TARs). 

To W-2, W-3, W-4: March 23. 

To Lieutenant (Line): April 13 (includes Waves). 

To Lieutenant Commander (Staff): (includes Waves 
and TARs). 

To Lieutenant (Staff): April 20 (includes Waves, 
same membership as lieutenant commander board). 



NEW-TYPE MOB ORDERS ON WAY TO 
RESERVISTS* 

Those card-type mobilization orders are fast dis- 
appearing and a new type of mobilization order is being 
distributed. 

These new orders are about 4" by 8" and can be 
folded easily for insertion in the wallet where they 
should be carried at all times. 

The new MOB orders are a tear-off form, prepared 
at the Naval Reserve Manpower Center in Bainbridge, 
Md. In most cases, they direct the holder where and 
when to report to mobilization. 

The high-speed machines at Bainbridge now make it 
possible to correct and re-issue MOB orders more fre- 
quently to reflect not only changes in the Navy's 
anticipated mobilization requirements, but also to reflect 
the individual officer's promotion, change of address, 
etc. 

The Manpower Center expects to be making the 
change at the rate of about 6000 a month. Officers 
with the old card-type orders should destroy them after 
receiving their new tear-off form MOB orders. 

Any officer who feels an error has been made in 
writing of his orders, should request a change, via the 
chain of command, to the Commanding Officer, Naval 
Reserve Manpower Center, Bainbridge, Md. 



MISCELLANY 



REPORT ON NEW BUMED FILM, 

"HYGIENE FOR WOMEN" 

(MN-8268 A, B & C) 

Mr. Charles A. Green, Film-TV Production Division, 
U.S. Naval Medical School, NNMC, Bethesda, Md. 

Each new generation of young people in the Service 
needs reminders, tailor-made to its own cultural dimen- 
sions, of principles that are as old as time. The planners 
and producers of a new three-part BuMed film, in 
color, "Hygiene for Women" (MN-8268 A, B & C), 
had this fact well in mind. The ideas expressed in the 
series are as sound and proven as their vehicle is modern 
and well-dressed. 

The three parts are really separate and independent 
pictures under a general title. Part A, subtitle "Per- 
sonal Health", is nineteen minutes long and has to do 



with cleanliness, diet, exercise, posture and grooming. It 
makes the big point that the individual girl (and a most 
attractive one she is in all three of these pictures), 
can personally aid her own health and appearance and 
thereby contribute to the health and efficiency of the 
outfit of which she is a part. Offering good rules about 
eating and going on to very personal instructions like 
how to trim one's toenails after a shower, the picture 
is a graphic guide for any young woman, in or out of 
the military service. 

Part B is subtitled "Reproduction and Menstruation" 
and is eighteen minutes long. The idea here is to let 
the viewer know these normal processes for what they 
are: normal processes. The film uses a combination 
of live photography and animation to explain the sexual 
organs, both male and female, and their function in the 
reproductive system. It tells the purpose of the menstrual 



20 



U.S. NAVY MEDICAL NEWS LETTER 



cycle and shows how it functions. The film points up 
the importance of good health and proper personal 
care in connection with menstruation, and adds the 
reassurance of telling why there can be variations in 
the normal menstrual cycle. 

The subtitle of Part C, "Protecting Health", is a 
severely simple label for the large subject it discusses: 
The importance of self-control in social conduct, spe- 
cifically drinking and sex relationships, as a means of 
protecting well-being. With honesty and calm, this film 
steps in where many a parent fears to tread; it engages 
and holds attention to matters from which many a 
young person simply walks away with a shrug and a 
"Don't tell me; I know all that." The picture dramatizes 
the effects of alcohol on the body and tells how to con- 
trol them; it goes further than to say merely, "Don't 
drink." Then, in contrast to drinking as an acquired 
practice, the film discusses the sexual urge as entirely 
natural. It quietly dramatizes the possible results of 
illicit relations: illegitimate pregnancy, venereal disease, 
psychological upset. But the emphasis is on the basic 
fact that affection and sexual attraction are normal; the 
film offers principles that may aid in self-control in 
dating. Screen time is twenty-six minutes. Most of the 
action is live, but the transfer of disease from person to 
person and its effects on the body are in animation, and 
there is some engaging animation that symbolizes the 
tugging of emotions in the experience of the young 
adult. 

These three films are intended for use by officers 
who train and supervise young women in the Service. 
Their series title "Hygiene for Women," however, should 
not suggest that they are suitable exclusively for female 
viewers. And instructors may find that they have an 
unexpected and enthusiastic additional audience in their 
own daughters (and sons). 

Prints have been distributed to Naval Hospitals, Naval 
District libraries and certain special stations where 
there are large numbers of Navy women. 

SOME GUIDELINES CONCERNING THE 

WEARING OF CONTACT LENSES 

BY ACTIVE DUTY PERSONNEL 

Many recruits, who ordinarily wear contact lenses, 
are reporting to recruit training without their lenses. 
This causes unnecessary delay in starting their training 
due to the time it takes to complete an eye examination 
and fabricate conventional spectacles. 

The Manual of the Medical Department, Chapter 
15-13 (3)(f)(14), specifies that defective vision, cor- 
rective only by contact lens, is cause for rejection. It 
is not the Bureau's intention that this statement preclude 
any applicant from wearing contact lenses while on 
active duty, provided that his vision is also correctible 
to standards by conventional spectacles. 

The purchase of contact lenses by Navy or Marine 
Corps personnel, at their own expense, is not prohibited. 



However, the Government is under no obligation to 
provide or replace such lenses. It is noted that all per- 
sonnel in the service who require spectacles shall be 
examined as necessary and provided with spectacles as 
indicated in BuMedlnst. 6810. 4B. 



DR. HENRY A. IMUS HONORED BY THE 
AMERICAN PSYCHOLOGICAL ASSOCIATION 

The American Psychological Association has estab- 
lished an award in memory of Henry A. Imus, Ph.D. 

Dr. Imus, at the time of his death, May 18, 1964, 
was Deputy Director of Research at the Naval School 
of Aviation Medicine, Pensacola, Fla. 

The award will be given annually in recognition of 
outstanding research performed, in the preceding year, 
by a junior member of the military or civilian research 
staffs of the military services, according to Dr. S. B. 
Sells, a member of the APA. 

Dr. Sells said that the award would be a perpetual 
reminder of the years of devoted service that Dr. Imus 
spent in furthering research through sponsorship and 
personal encouragement. He further stated that the 
members of the Division of Military Psychology were 
happy to be afforded the opportunity to express their 
admiration for Dr. Imus, both as a person and as a 
scientist. — P.I.O., USN Aviation Med. Center, Pensa- 
cola, Fla. 



EGYPTIAN DOCTOR TO CONDUCT HEART 

RESEARCH AT THE NAVAL SCHOOL OF 

AVIATION MEDICINE 

Dr. Hassan H. Khalil of Alexandria, Egypt has re- 
ported to the Naval School of Aviation Medicine, Pensa- 
cola to conduct heart research related to space flights. 
He is the assistant professor in the Department of 
Medicine at the University of Alexandria. 

During his tour here he will work with Captain 
Ashton Graybiel, Medical Corps, USN, Director of 
Research at the School of Aviation Medicine. 

He is conducting research on a new method for 
measuring the blood output per minute. This method 
has proven to be very simple, rugged and susceptible to 
being used in space flight research when using telem- 
etry equipment — electronic devices for measuring pres- 
sure, temperature, radiation, etc., and transmitting the 
information to a distant receiver: now used in the 
study of outer space. 

This isn't Dr. Khalil's first visit to the United States. 
In 1963 he conducted research at the University of 
Mississippi Medical Center, Jackson, Miss., and at the 
Cardiovascular Research Institute, University of San 
Francisco. 



U.S. NAVY MEDICAL NEWS LETTER 



21 



Dr. Khalil, who also holds a doctorate in philosophy, 
Was accompanied to this country by his Swedish wife 
and three-year-old daughter, Karima. The Khalils also 
have a son, Taher, 16, who is in his second year of 



medical school at the University of Alexandria. He 
is now the youngest of all students to ever attend a 
medical school in Egypt. — P.I.O., USN Aviation Med. 
Center, Pensacola, Fla. 



ROADWAY ELEMENTS AND 
HIGHWAY SAFETY 

The relationship of traffic accidents to roadway 
design and traffic control has long occupied highway 
and traffic engineers. "Traffic Control and Roadway 
Elements," a 1963 publication based on a study by 
David W. Schoppert of the Automotive Safety Founda- 
tion, provides a comprehensive collection of research 
data on the subject. Based on exhaustive review and 
analysis of engineering studies in the United States and 
abroad, the study relates accident rates to such factors 
as traffic volume, proportion of heavy vehicles, type 
and width of highway and shoulder, road alinement, 
highway dividers, guardrails, roadside trees, ramps, pro- 



tective devices at intersections and rail crossings, vehi- 
cle speeds, one-way streets, streetside parking, and pro- 
vision of sidewalks. 

According to the publication, past studies have ex- 
plored only the relationship between the roadway fac- 
tors and traffic accidents; a general theory of accident 
occurrence must be stated in terms of the impact of 
those same factors on drivers or on the traffic stream, 
with impact translated into likelihood of accident occur- 
rence. The U. S. Bureau of Roads and the Automotive 
Safety Foundation, which jointly financed the study, 
hope its publication will "foster wider and more uniform 
application of design features of proven safety value 
and spur future searches for additional facts." — Public 
Health Reports, 79(5): 423 May 1964. 



DEPARTMENT OF THE NAVY 

U. S. NAVAL MEDICAL SCHOOL 

NATIONAL NAVAL MEDICAL CENTER 

BETHESDA. MARYLAND 20014 

OFFICIAL BUSINESS 

PERMIT NO. IQ4B 



POSTAGE AND FEES PAID 
NAVY DEPARTMENT 



L'EDICAL TECHNICAL LIBRARY 

- iDic-AH ar;:y hospital 

lACQilA, Er ! A3Hir,'GT0»N L 



10-9 



22 



U.S. NAVY MEDICAL NEWS LETTER